Diagnostic Procedures

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3.1 Fine Needle Aspiration

Fine needle aspiration (FNA) is a quick way to diag- nose malignancy in a patient with a breast mass.

First, the skin is cleaned with rubbing alcohol. The surgeon then fixes the tumor with his or her hand, using either the thumb and index finger or index fin- ger and middle finger. A syringe attached to a 21- gauge needle is then placed into the breast mass while suction on the syringe is maintained (Figs. 3.1, 3.2, 3.3). We generally use a 20-ml syringe for this purpose. The needle is passed through the breast mass in various directions (but never brought out of the mass), while maintaining suction on the syringe.

Suction is then released and the needle brought out of the breast mass. The tissue debris on the nee- dle and tip of the syringe is sprayed onto glass slides,

Chapter 3 Diagnostic

Procedures

using the syringe plunger. The slides are air-dried and subsequently stained and processed by the pa- thologist (Fig. 3.5a, b) to assess for the presence of malignant cells. If malignant cells are identified, this usually indicates the presence of invasive carcinoma, because ductal carcinoma in situ (DCIS) is rarely pal- pable, and generally presents as an abnormality seen only on mammogram. Yet, to completely exclude the possibility of DCIS, an excisional biopsy is required.

When assessing a breast mass for malignancy, FNA has a very low false-positive rate. However, the false-negative rate is much higher. Therefore, if no malignant cells are detected on FNA (Fig. 3.5a), many surgeons will proceed with excisional biopsy to defi- nitely exclude the possibility of cancer. However, in most cases FNA should be performed under ultra- sound guidance (Fig. 3.4).

Fig. 3.1.Fine needle aspiration of a palpable breast mass

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3.1 Fine Needle Aspiration 20

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Fig. 3.2.Equipment required for the punction of breast cysts

Fig. 3.4.Ultrasound guided biopsy after local anasthesia

Fig. 3.3.FNA of a 63-year-old patient presenting with a new finding after TRAM flap surgery for invasive breast cancer Equipment for punction of cysts:

Syringes 20 ml

Cameco syringe pistol (optionally) Needle (20 g, 7 cm preferred)

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Chapter 3

Diagnostic Procedures 21

Fig. 3.5a, b. a Fine needle puncture: normal breast epithelial complex (× 400).bFine needle puncture: tumor cells from solid breast cancer (× 400)

a

b

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3.2 Core Needle Biopsy

¹

The technique of core needle biopsy can be applied to both palpable and nonpalpable breast lesions. If the lesion is palpable, image guidance is generally not necessary. The skin overlying the breast mass is cleaned with rubbing alcohol and local anesthetic is injected around the intended biopsy site A small cut is made on the skin overlying the breast mass using an 11-blade knife, and the tip of the biopsy instru- ment (Fig. 3.6) is placed against the mass. The breast mass is then stabilized with one hand, and the biopsy instrument fired with the other hand. Caution should be used when stabilizing the lesion by hand. The bi- opsy needle is thrust forward about 2 cm when fired, and can injure the assisting hand. The tissue samples are placed in formaldehyde, and submitted to pathol- ogy. The surgeon should inspect the tissue samples in the formaldehyde. If the tissue floats, this generally indicates that the sample is not adequate, and addi- tional tissue should be obtained. After obtaining ade- quate tissue, a band-aid is placed over the cut.

For nonpalpable lesions, visualization with either ultrasound or mammography is required to obtain core biopsy samples (Fig. 3.7).

When performing an ultrasound-guided biopsy, local anesthetic is injected around the intended biop- sy site. A small incision is made with a number 11- blade scalpel to allow entry of the biopsy needle into the breast. The entry point should be made about 1–2 cm away from the ultrasound transducer probe, which allows the surgeon to visualize the breast le- sion. The surgeon should test-fire the biopsy gun and become familiar with its firing mechanism before placing the spring-loaded needle into the breast tissue.

The surgeon can generally hold the ultrasound probe with one hand and manipulate the spring- loaded needle with the other hand. However, it is of-

ten helpful to have a technician stabilize the ultra- sound probe, giving the surgeon additional flexibility to manipulate the biopsy instrument. The needle should be directed to the edge of the area of concern, and photo-documentation of the image completed.

The patient should then be warned that the biopsy instrument is about to be fired. The instrument is then fired, obtaining the necessary core biopsy sam- ples of the breast lesion. After completing the proce- dure, the biopsy specimens are placed in formalde- hyde and sent to the pathologist, and a band-aid is placed over the breast wound.

A vacuum-assisted breast biopsy system and the result are shown in Fig. 3.8, 3.9, 3.10.

The term “stereotactic breast biopsy” refers to a method of sampling (Figs. 3.8, 3.9) breast lesions that are visualized mammographically (Fig. 3.10). The mammograms should be carefully reviewed to deter- mine the best directional approach to the lesion. A computer calculates the coordinates for horizontal, vertical, and depth axes, so as to direct the attached core needle device to the targeted lesion on the breast (Fig. 3.11). The patient is positioned prone on the pro- cedure table, with the breast in the dependent posi- tion through an aperture on the stereotactic table (Fig. 3.12, 3.13). The skin overlying the breast is cleaned with povidone-iodine (Betadine®) solution or alcohol, and the needle entry site should be infil- trated with local anesthetic prior to making a small skin incision with an 11-blade knife. The needle is then manually advanced to the appropriate depth as calibrated by a computer, and stereo images are taken to ensure correct position of the needle tip in relation to the breast lesion. The spring-loaded needle is then fired into the breast lesion, and the appropriate loca- tion of the core biopsy confirmed with repeated ster- eo images. The core biopsy samples obtained in this manner (Fig. 3.14) are submitted to pathology togeth- er with radiographs (Fig. 3.15, 3.16, 3.17) and a band- aid placed over the small cut on the breast.

3.2 Core Needle Biopsy 22

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1 (Illustrations are courtesy of Christine Solbach MD, Depart- ment of Obstetrics and Gynecology, and Thomas Diebold MD, Department of Radiology, Goethe University, Frank- furt, Germany)

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Chapter 3

Fig. 3.6.High-speed core-cut biopsy instrument. The example shown is an Angiomed BARD MAGNUM, with 12/14 or 16 g probes, length 100 mm, biopsy diameter 1.9 mm

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Fig. 3.7.When taking high-speed core-cut biopsy samples of nonpalpable and palpable breast masses, visualization with ultrasound may be required

Fig. 3.8.The vacuum-assisted breast biopsy system allows punction, aspiration, resection, and removal of breast lesions that are visualized mammographically throughout the procedure (Ethicon Endo-Surgery)

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Chapter 3

Fig. 3.9.A vacuum-assisted percutaneous biopsy device and biopsy needle (brand name Mammotome®, manufactured by John- son and Johnson Ethicon Endo-Surgery)

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Fig. 3.10.Using the vacuum-assisted breast biopsy system, the probe is positioned at the lesion. It vacuums, cuts, and removes tissue samples, which are passed through the probe’s hollow chamber into a collection tray. This allows for multiple samples to be collected while only one incision into the breast is made. At the end hematoma remains visable

Fig. 3.11.The core needle device of the vacuum-assisted breast biopsy system, showing the hollow probe and specimen collection tray

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Chapter 3

Fig. 3.12.The vacuum-assisted biopsy system shown in place, below the aperture in the stereotactic table

Fig. 3.13.The surgeon or radiologist can rotate the thumb- wheel of the vacuum-assisted biopsy probe, moving it to the correct position for the next biopsy sample, to allow multiple samples to be taken with just one breast incision

Fig. 3.14.Multiple core biopsy samples obtained following one vacuum-assisted biopsy procedure

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Fig. 3.15.Ductal carcinoma in situ (DCIS) in a specimen obtained by vacuum-assisted biopsy

Fig. 3.16.Excision biopsy specimen after prior vacuum-assisted biopsy

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Chapter 3

Fig. 3.17.Excision biopsy specimen after prior vacuum-assisted biopsy

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3.3 Overview of Biopsy Techniques

As indicated on the previous pages, there are several methods available to biopsy breast tissue (Figs.

3.18a–d, 3.19a–d, 3.20). The optimal method depends on the amount of tissue required and the objective of the biopsy (whether to completely excise a breast le- sion or simply obtain a sample) (Fig. 3.19a–d). The greatest amount of tissue is obtained with open biop- sy techniques (excisional biopsy or needle-localized

biopsy; Fig. 3.19a), and decreasing amounts are ob- tained by biopsy with the advanced breast biopsy in- strument (ABBI) system (Fig. 3.19b), core biopsy (Fig. 3.19c), and vacuum-assisted biopsy (Figs. 3.8, 3.9, 3.10, 3.19d). The more tissue required, the greater the size of the incision required for the procedure.

Thus, a very small incision is required for vacuum- assisted biopsy, and increasingly larger incisions are required for the core biopsy, ABBI system, and open biopsy methods.

3.3 Overview of Biopsy Techniques 30

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Fig. 3.18a–d.Comparison of different biopsy techniques, their invasiveness, and the amount of tissue sampled.aExcisional or needle-localized biopsy;bthe advanced breast biopsy instrument (ABBI) system;ccore biopsy;dthe stereotactic vacuum-assisted biopsy device

a b

c d

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Chapter 3

Relation biopsy- lesion

Excisional or needle-localized biopsy

ABBI system

Core biopsy

Breast (stereotactic) biopsy

Fig. 3.19a–d.Comparison of different biopsy techniques, their invasiveness, and the amount of tissue sampled.aExcisional or needle-localized biopsy;bthe advanced breast biopsy instrument (ABBI) system;ccore biopsy;dthe stereotactic vacuum-assisted biopsy device

a b

c d

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3.3 Overview of Biopsy Techniques 32

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Fig. 3.20.Examples of core-cut (left) and vacuum-assisted (right) specimens

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3.4 Needle-Localized Biopsy

A needle-localized biopsy (Fig. 3.21) is performed to assess abnormalities of the breast that are not palpa- ble but are seen on mammogram. To obtain tissue for histological evaluation, the surgeon requires the as- sistance of the radiologist to localize the mammo- graphic abnormality with a hooked wire.

The patient is first transported to the radiology suite, where the mammographic abnormality is lo- calized with a hooked wire (Fig. 3.22). Proper place- ment of the wire within the abnormality is essential.

Mammograms with two views (anterior–posterior and medio–lateral) should be obtained showing the wire and its relationship to the abnormality. These mammograms guide the surgeon during dissection.

The patient is transported to the operating room with the wire in place. Care should be taken to ensure that the wire is secured on the surface of the breast during transport. The outer part of the wire should be carefully taped on the surface of the breast.

The needle-localized biopsy can be performed us- ing either local or general anesthetic, depending on preferences of the patient and surgeon. The tape is carefully removed from the wire and surface of the breast, and a wide area of the breast is cleaned with a sterilizing solution. A curvilinear incision is made

immediately adjacent to the wire, along the direction of one of the natural skin crease lines (lines of Lang- er). Hooks are used to lift up the edges of the skin.

With the needle-localized mammograms serving as a guide, the wire and tissue around it is removed en bloc by sharp dissection. Electrocautery should be avoided during dissection, as this can create artifacts that obscure pathological assessment of the speci- men. However, once the wire and breast tissue around it are removed, meticulous attention is paid to achieving hemostasis with electrocautery.

It should be emphasized that the incision should be placed near the wire. Periareolar incisions and in- framammary incisions are not recommended, unless the wire is immediately adjacent to these areas (Fig. 3.23, 3.24).

Once the breast tissue (with the wire in it) is re- moved, the specimen is transported to the radiology suite. A specimen film is obtained to confirm exci- sion of the mammographic abnormality. After this is done, the breast wound is irrigated, and skin edges are re-approximated using a running absorbable subcuticular stitch.

Figure 3.22a–c shows: (1) a mammographic abnor- mality with a wire localizing it (medio-lateral view);

(2) a mammographic abnormality with a wire local- izing it (craniocaudal view); and (3) a specimen film of the completely excised mammographic abnormal- ity with the wire through it.

Chapter 3

Fig. 3.21.Needle-localized biopsy 1

2

3

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3.4 Needle-Localized Biopsy 34

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Fig. 3.22a, b Mammogram of the right breast.cRadiograph of the breast tissue specimen with microcalcifications (magnifica- tion 2 fold)

a

b

c

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Chapter 3

Fig. 3.23.Guidance for correct approach during needle-localized biopsy. The posterior glandular approach (1 on right) is recom- mended, whereas periareolar (2 on right) is not recommended. Inframammary approach (3 on right) is only recommended if the tumor is deeply located

Recommended 1.

2.

Not recommended

3.

Recommended

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3.4 Needle-Localized Biopsy 36

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Fig. 3.24.Needle-localized biopsy

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3.5 Microductectomy

This technique is used to excise a single breast duct, usually to diagnose the cause of nipple discharge from a single duct. If bloody nipple discharge arises from a single duct, it is often attributable to a papil- loma.

Surgical procedures around the nipple–areola complex are uncomfortable for the patient, and many surgeons prefer to use a general anesthetic. A cathe- ter attached to a thin butterfly syringe is used to in- still blue-dye into the lactiferous duct and sinus (Fig. 3.25a, b). The catheter is removed, and a periare- olar incision made. Tissues are dissected down to the duct containing the blue-dye. The duct is excised and

submitted for pathological evaluation. Afterwards, meticulous attention should be paid to achieving he- mostasis with electrocautery. The wound is then irri- gated, and the skin edges re-approximated with a running subcuticular absorbable stitch.

Alternatively, a periareolar incision can be made and the areolar lifted up with a skin hook (Fig. 3.26).

The area of breast tissue that includes the involved duct (or ducts) is broadly excised, extending the area of excision posteriorly. Once the tissue is excised and hemostasis is obtained, the posterior extent of the ex- cision within the breast can be re-approximated with interrupted absorbable stitches, and the nipple–areo- la complex re-attached to the adjacent skin with a running 3–0 Monocryl subcuticular stitch.

Chapter 3

Fig. 3.25a, b.Microductectomy.aBlue-dye is injected into the lactiferous duct and sinus using a thin butterfly syringe.bTissue stained by the blue-dye is removed (dotted line)

a

b

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3.5 Microductectomy 38

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Fig. 3.26.Ductectomy through a periareolar incision

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3.6 Subareolar Dissection

A subareolar dissection is required to extirpate the major ducts immediately below their opening at the nipple (Fig. 3.27). This procedure is often used to di- agnose or treat persistent nipple discharge (usually unilateral) arising from many ducts. In many cases, such discharge is attributable to duct ectasia. Howev- er, there are other causes of profuse nipple discharge involving many ducts, particularly if the discharge is bilateral, including a prolactin-secreting tumor.

Therefore, patients must undergo thorough assess- ment prior to surgery.

This procedure is usually performed under a gen- eral anesthetic. After applying a sterilizing solution over the entire field, a periareolar incision is made, and the major duct system immediately below the nipple–areola complex is excised. Meticulous atten- tion is paid to hemostasis using electrocautery. The

wound is copiously irrigated, and the skin edges are re-approximated with a running absorbable subcut- icular stitch.

Chapter 3

Fig. 3.27.Subareolar dissection, required to extirpate the major ducts immediately below the nipple

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3.7 Mammary Ductoscopy

Figures 3.28–3.34 are courtesy of Professor Kefah Mokbel, London, UK.

Mammary ductoscopy is relatively new technolo- gy and its potential applications are still under inves- tigation. However, it has been used to diagnose the source of discharge from a single breast duct (Fig. 3.28). The orifice of the breast duct is dilated, and a small endoscope is passed through it into the ductal system. The small endoscope contains a came- ra, and this allows for direct visualization of the intraductal system on a television screen. Thus, intra- ductal pathology can be visualized, allowing for ade- quate removal of intraductal lesions while preserving surrounding normal breast tissue.

The ductoscopes that are now frequently used are 1.0 mm in external diameter with a 0.45 mm working channel (Fig. 3.29), allowing air insufflation and sa- line irrigation during visualization. The working channel provides for ductal dilatation, sampling of intraductal lesions, and also permits irrigation of de- bris, thereby providing a clear image (Fig. 3.30). Duc- toscopes have been utilized in the management of nipple discharge, to help determine the underlying cause of the discharge. Additionally, lavage of the ductal system through the ductoscope (ductal lavage) is under investigation as a means of harvesting epi- thelial cells, examining these cells for evidence of aty- pia or malignancy (Figs. 3.31, 3.32, 3.33 and 3.34), and thereby assessing women at high risk for developing breast cancer.

3.7 Mammary Ductoscopy 40

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Fig. 3.28.Mammary ductoscopy and pathologic nipple dis- charge (PND)

Fig. 3.29.The endoscope, which has an external diameter of 1 mm, a 0.45-mm working channel and a resolution of 10,000 pixels

Fig. 3.30.The procedure

Fig. 3.31.Normal mammary duct visualized on ductoscopy

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Chapter 3

Fig. 3.32.Papilloma visualized on ductoscopy

Fig. 3.33.Ductal carcinoma in situ (DCIS) visualized on ductoscopy

Fig. 3.34.Ductoscopic cytology (DCIS)